病例:罕见并发症肉毒毒素注射后继发皮肤感染

2019-12-29 Chen, X 肉毒毒素btxa

脓肿分枝杆菌是一种快速生长的非结核分枝杆菌,广泛存在于水、土壤和灰尘中,通过与污染的材料或水直接接触引起皮肤、软组织、呼吸和中枢神经系统的感染。过去十年来皮肤脓肿感染的发病率增加。大多数报道的病例与创伤、手术或美容手术有关,包括自体脂肪注射、美塑治疗、纹身、甚至毛发移植。

脓肿分枝杆菌

脓肿分枝杆菌是一种快速生长的非结核分枝杆菌,广泛存在于水、土壤和灰尘中,通过与污染的材料或水直接接触引起皮肤、软组织、呼吸和中枢神经系统的感染。过去十年来皮肤脓肿感染的发病率增加。大多数报道的病例与创伤、手术或美容手术有关,包括自体脂肪注射、美塑治疗、纹身、甚至毛发移植。

今天,我们要看一下来自北京大学人民医院皮肤科医生报告的2个罕见病例,患者面部注射肉毒毒素后继发了脓肿感染。

案1例



32岁女性患者,在非医院机构的非医疗工作人员进行肉毒毒素注射后,其前额和眶周区域(如上图)出现多发性疼痛结节和脓肿,有2个月之久。

肉毒毒素注射后1周,所有注射部位开始出现红斑丘疹和结节,并逐渐发展为脓肿伴溃疡和结痂。随后,她作为一例过敏反应患者,口服强的松30mg/d,静脉注射阿奇霉素,继发性脓疱化,患者对治疗结果不满意。在强的松停药1周后,皮损复发。皮肤活检显示淋巴细胞、组织细胞、浆细胞、嗜酸性粒细胞和中性粒细胞密集混合浸润。脓液齐尔-尼尔森染色阳性。采用抗酸杆菌培养和限制性片段长度多态性分析,对hsp65聚合酶链反应产物进行测序,证实脓肿为脓肿分枝杆菌引起。克拉霉素250 mg每日两次,利福平450 mg每日一次,乙胺丁醇250 mg每日三次治疗3个月后,皮损完全消失,随后出现色素沉着和萎缩性瘢痕(见下图)。



案2例

34岁女性患者,由在一家化妆品研究所工作的无执照医生将肉毒毒素注射到她的咬肌后,在她的下颚、颧骨和太阳穴区域(如下图A)出现多处柔软、波动和疼痛的丘疹和结节。患者在注射后48小时内潜水。



10天后,所有注射部位均出现疼痛性红斑丘疹和结节。皮质类固醇联合口服青霉素、庆大霉素及清创治疗无效。血常规检查结果在正常范围内,头颅超声显示软组织内有混合回声。齐尔-尼尔森染色阳性。6个月后,脓液培养4周后,用显色和荧光培养基培养,产生了被鉴定为脓肿分枝杆菌。患者接受克拉霉素250毫克每日两次和利福平450毫克每日近6个月的治疗。炎症后色素沉着和增生性瘢痕消退。



案例总结

1肉毒毒素最常见的不良反应是暂时的,并且可以自愈,包括疼痛、发红、肿胀、瘀伤、注射部位感染和肌肉僵硬/无力。当注射部位在注射肉毒毒素后几周内出现红斑、结节和脓肿时,应首先考虑感染。

2本案例的患者都是在非医疗环境和非医疗专业人员进行的。由于灭菌过程不标准而导致感染的风险很高。非法销售的来源不明的不合格肉毒毒素,在生产、运输、储存过程中也可能受到污染,从而造成问题。第二例患者潜水期间暴露在高压海水中也应被视为潜在的危险因素。

3免疫功能正常的患者皮肤脓肿分枝杆菌感染通常局限于局部。典型的皮肤表现为结节、斑块、蜂窝织炎、溃疡、瘘管形成和囊性改变,有压痛或起伏。齐尔-尼尔森染色显示多种阳性结果。常规细菌培养阴性有时难以确诊,因此用显色和荧光培养基培养耐酸杆菌是必要的。

4虽然皮肤脓肿感染没有标准的治疗方法,但根据药敏试验,大环内酯类抗生素,如克拉霉素联合其他抗生素治疗,建议作为至少4个月的初始治疗,必要时切开引流。

参考文献略。

原始出处:

Chen, X., Jin, Y., Torres, K. M. T., Li, B., Zhuo, F., Ding, X., … Zhou, C. (2019). Mycobacterium abscessus cutaneous infection secondary to botulinum toxin injection: A report of 2 cases. JAAD Case Reports, 5(11), 982–984. doi:10.1016/j.jdcr.2019.09.017

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    2020-05-12 feifers
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    2020-05-31 丁鹏鹏
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    2019-12-31 syscxl

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